A Bacterial Profile of Nosocomial Infections in a Tertiary Care Hospital

Background: Nosocomial infections, may appear either during the hospital stay of the patient or after discharge. Objective: To find out the bacterial profile of nosocomial infections in a tertiary care hospital. Methodology: This cross-sectional study was based on the records of the patients admitted in Ghurki Trust Teaching hospital during the period of January 2016 to December 2017, who developed infections after their hospital admission, and their record was available in the Microbiology section of the Department of Pathology. A total of 1000 complete records of the patients were retrieved. Bacterial culture tests from clinical samples of these patients were performed in the clinical microbiology Laboratory of Lahore Medical and Dental College. Specimens included in this study were urine samples, pus samples from wound discharge, infected implants, and dead necrotic tissue. Data were analyzed using SPSS version 26. Results: Out of 1000 samples, 150 (15%) samples showed positive growth, and among 150 83 (55%) were from females patients. The bacterial profile of these 150 positive samples showed that the most frequently isolated bacteria were Staphylococcus Aureus 45 (30%), MRSA 45 (30%) followed by Klebsiella, 21 (14%), Pseudomonas 15 (10%), E. Coli 12 (8%), Acinetobacter 9 (6%), and Proteus 3 (2%). Conclusion: Staph. Aureus, MRSA, Pseudomonas, Acinetobacter, Klebsiella, E.Coli and Proteus are frequently isolated bacteria from nosocomial infections in our study. Such studies should be done frequently to keep track of bacteria that are prevalent in hospital-acquired infections.

Quality Management in Healthcare System; where we stand?

Quality management in healthcare can significantly and efficiently change the health system performance and patient satisfaction. It improves every aspect of the health system such as system or process, its functions, and goals, in a systematic evidence-based manner. A health system is anorganization of persons, institutions, and the resources which deliver health care services to fulfill health needs of the populations.1 A health system includes public sector facilities and private facilities, which deliver preventive, curative, and the personal health services. It also includes in it, theprograms which focus on behavior change, and vector-control program, financing methods like health insurance systems, inter-sectoral coordination, and legislation. The goals for the health system include; providing good health for its citizens, being responsive to the expectations of population it serves, and fair financing services. The achievements towards these goals is based on how effectively and efficiently, a health system carries out the following key functions including, provision of quality health care services, resource generation, financing, and overall stewardship.1 The outcome of the health system is not based on these factors only, in fact, it is based on multiple interrelated factors, which in turn are governed by the concepts, and principles of quality management in healthcare. There are many established quality standards that may work as a yardstick in a journey to achieve the goals of the healthcare system in a country. There are multiple key concepts in quality management of healthcare system such as healthcare services are very specific and unique, because of continuous physical and mental interaction of the patients and healthcare providers (HCP) in the process of health services provision, and patients usually have little knowledge of medical services. As in the input, process, and output model of a system, this interaction of the patient with HCP shall define the process and output of the system. So whether it is effective interaction or not will be the deciding the quality of healthcare and thus a satisfied patient at the end. Additionally, these interactions are not the only thing important in an effective treatment and quality of healthcare. The related factors which are also very pertinent to mention like payments type and sources, suppliers of the medical and non-medical equipment, materials and resources, healthcare financing in the form of insurance, legislative and other regulatory bodies, so emphasizing the complex nature of the healthcare quality management. Quality management principles are widely followed in a diverse range of systems and disciplines and the healthcare system is not an exception. The key principles of quality management in healthcare include; it should be patient-centered, all the stakeholders should have the say, including not only patients and HCPs, but paramedical staff, managers, political and financers. Leadership skills for quality, shared vision of care, process orientation by staff, partnership, third party services, continuous improvement, and use of modern technologies.2,3In the light of the concepts, principles, and standards, of the quality management system in the healthcare organizations brings a revolutionary change in the healthcare systems. Quality management affects every aspect of a health system from ownership to structure, and patient-doctor relationships so positively affect the goals of the health system and patient satisfaction. The health system comprises mainly private healthcare services to about seventy percent of patients and public healthcare services to remaining patients.4 Healthcare system in Pakistan is facing scarcity of financial resources, coupled with the double burden of communicable and non-communicable diseases. Although Pakistan has an adequate qualified human resources for healthcare service delivery, there are serious gaps in the planning, resulting in the poor quality of healthcare services. Still, the vast majority of the public and private hospitals in the country, are not certified with ISO 9001:2015, which specifically focuses on performance in a healthcare setting.5 Although international organizations like World Health Organization, continue to emphasize its importance for our health system, healthcare quality management is a neglected academic specialty in the country. Recently there has been an increasing emphasis seen on this relatively new concept of quality in healthcare, after more and more qualified people joining this discipline. The development of healthcare quality management mainly depends on the value and priority given by the leadership at all levels, to integrate and implement quality management with in the healthcare delivery system in a country. Although some progress has been made recently by Healthcare commissions in provinces there is a lack of a comprehensive national healthcare accreditation system and national guidelines, on healthcare quality and patient safety. Additionally, we still don,t have established national quality care indicators. In both private and public sector healthcare establishments, organizational culture is absent, and leadership, to prioritize quality management in healthcare. The ambiguity in the regulatory role of PMC (Former PM&DC), Healthcare commissions at federal and provincial levels was another hurdle at the legislative and policy level.6 It is suggested that healthcare policymakers and planners in the country start realizing the importance of quality management in healthcare and devise a system to integrate quality improvement initiatives at the planning stage of the healthcare system. This would make our health system efficient and thus maximum benefit could be gained from the resource-constrained healthcare system and would restore the much-needed patient trust in the healthcare system of our country.

Drug Addiction in Pakistan: A step towards alleviation of sufferings

Addiction is a complex mental and behavioral disorder that changes the neurochemistry and physiology of the brain. Genetics also plays a significant role in the pathophysiology of addiction.1 Drug addiction, whether it is mono or poly drug addiction is a major problem in Pakistan, it is defined as a maladaptive form of drug or illicit use leading to clinically significant distress or impairment, while an individual may also suffer from withdrawal and tolerance. As we know that drug addiction or abuse is a common problem worldwide, including Pakistan.2 According to World Health Organization (WHO), Pakistan is categorized as low income country of Eastern Mediterranean Regional Office (EMRO) region with a population of more than 20 million people among which, 97% of Pakistani population is predominantly Muslim, with highly conventional customs and traditions governing the lives of many people. These people showed to follow Islamic and cultural norms and values. All substances of abuse are publicly despised in Pakistani culture, also in their religion. Usage of drugs consider harmful and known to be prevalent among people. Government does warranting determinations to increase awareness about harmful effects of drugs and to change attitudes of people and prevention of the addiction.3In Pakistan, the prevalence of drug addiction is increasing at an alarming rate. According to United Nations Office on Drugs and Crime (UNDOC) and the reports of United Nations (UN), Pakistan has 7.6 million drug addicts, where 78% are males and 22% are females.4,5 However, the risk factors, which are increasing vulnerability towards addiction, remain largely elusive. The ratio of the problem of substance has increased and not decreased by any effort of the government. Pakistan became a marked trafficking route for illicit drugs, especially heroin, due to increased opium production in Afghanistan, and 2670 kilometers land border of Afghanistan is shared with Pakistan. Most of the drugs come from Afghanistan, a country that is held responsible for 75% of the world's heroin. UNDOC estimates that 800,000 Pakistanis aged between 15 and 64 used heroin regularly. Drug use or abuse became a more divergent dilemma in Pakistan, that's why Government of Pakistan takes a very serious notice of this matter of use, or addiction of illicit drugs or substance.6 Substances categorized as stimulants, sedatives, hallucinogens and opioids are being abused throughout the world including Pakistan. Addiction to opioids including other illicit substances is a chronic, relapsing multifactorial disorder of brain and, if left untreated, major medical, social, and economic problems arise. Substance addiction is among major health issues faced by the world including Pakistan. Its effect on physical and psychological health and become leading cause of other problems. Drug addiction can also be known as an initial chronic neurological problem, with hereditary, psychological, social, environmental and cognitive features that influence development and appearance of an individual or a person. Different behaviors as like the disturbed control or impulsivity for substance abuse and constant use of illicit substances deprived of harmful effects occurs due to addiction of drug.3 Substance use disorder such as opium, alcohol or other illicit substances is very serious community health problems now a days in Pakistan. Drug addiction is also associated with many risk factors like aggression, violence, isolation and emotion dysregulation. There are many established and significant psychosocial risk factors like parental relationship, lack of achievement and motivation, self-esteem, psychological stress and attention seeking behavior that are found positively correlated with substance abuse or addiction in Pakistan. A person who is stigmatized as addict has more negative social support from friends, family and others. The major reason behind this is that a person, who is dependent of drugs, has been rejected by the society due to substance addiction or his addictive behavior, but sometime a drug dependence has positive approach towards their friends and family because both support them in a good way, to take them away from the curse of addiction. While, those friends who never respond positively to drug dependence and they may be the cause for their substance usage, and may lead towards severe aggression and emotion dysregulation.6 Effects of substance addiction are always negative, it confirm that after substance addiction the addicts exhibit highly careless manners. Their income drop down and they reduce economic contribution in nourishment of their family. Mostly their earning is consumed on buying substance.7 The dependent members are liberated from dependence of addicts as they start economic activities of their own or the addicts are not capable of earning, hence deserted. The addicts lead miserable life as they remain under heavy debt as they take loan from friends and their poor health demand high expenditure with low economic performance. Drug abuse is hazardous and known to be prevalent among people, there is need to increase awareness about harmful effects and to change attitudes.7 There is need of educating our society specially students about the adverse effects and the moral and religious implications of substance abuse is more likely to have a positive impact than increased policing and prevention of drug use. There is lack student-counseling facilities, awareness programs, and rehabilitation centers in Pakistan. The health system need more progress for the prevention of drug addiction.Department of Psychiatry & Behavioral Sciences, inaugurated the 13-bedded Centre for Drug Addiction and Rehabilitation Centre at Sheikh Zayed Medical College/Hospital, Rahim Yar Khan on 20th February, 2020 in order to make the genuine effort towards the alleviation of sufferings. The vision is to transform the newly established center into the model addicts treatment and rehabilitation center (MATRCs).

Functional Ovarian cysts: Expectant management versus Oral contraceptives

Background: Ovarian cyst is a common problem in females of reproductive age group. Objective: To compare the expectant management and use of oral contraceptives for the management of ovarian cysts. Methodology: This was a comparative study, conducted in the department of Obstetrics and Gynecology, Sheikh Zayed Medical College, Rahim Yar Khan, from January 2017 to December 2018. A total of 870 females were included through non-probability, purposive sampling. Informed verbal consent was obtained. Ultrasound was performed to measure the cyst size, site, and characteristics. The lottery method was used to divide the patients into two groups. Patients in group E received expectant treatment (placebo) and in group OC, patients were prescribed hormonal treatment with combined oral contraceptive (COCP) having ethinyl estradiol 0.03mg and levonorgestril 0.15mg. Then patients were counseled and followed up for one month. After one month, USG was performed again to measure success as cyst resolution. The collected data was analyzed into SPSS 16. Both groups were compared for success by using the chi-square test, taking p-value <0.05 as significant. Results: Mean age of females was 26.42±7.59 years. There were 488 (56%) married females while 382 (44%) were unmarried. Mean cyst size was 3.93±1.28cm. was achieved in 605 (69.5%) females, out of which 259 (59.5%) had expectant management while 346 (79.5%) had oral contraception. Success (Cyst resolution) was achieved in 605 (69.5%) females, out of which 259 (59.5%) had expectant management while 346 (79.5%) had oral contraception. (p=0.00). Conclusion: It was concluded that oral contraceptives are more effective and successful in the resolution of ovarian cysts as compared to expectant management.

Prevalence and Psychological Impact of Acne on Quality of Life among Undergraduate Medical students of Lahore, Pakistan

Background: Acne Vulgaris is a rife and chronic dermal disorder, which commonly occurs in pubescent. This disease is characterized by the emergence of comedones, papules, pustules, nodules, or cysts which results from obstruction and inflammation of pilosebaceous units. Objective: To finding out the prevalence and psychological impact of acne on the quality of life in undergraduate medical students of Lahore, Pakistan. Methodology: A cross-sectional study was conducted during the month of October 2020, 291 among undergraduate medical students from eight medical colleges of Lahore, selected through simple random sampling, on both male and female undergraduate medical students. To assist them; they were given a simple grading criterion to self-diagnose their current acne severity and quality of life was evaluated by Cardiff Acne Disability Index. Data were analyzed by using SPSS version 22. Results: A total of 213 (73.2%) prevalence of acne was found among the participants who responded (291). No significant relation between acne severity and gender was found (p=0.151). There was no association between CADI score and gender (p=0.366). However, a significant correlation was found between CADI score and acne severity (p=0.000). In the population studied, 4.7% showed their acne severely impacting their quality of life, 27.7% have moderate, 58.7% have mild and 8.9% have no impact at all. Conclusion: High Prevalence rate of acne and its significant negative impact on QOL indicates that it is a very common dermatological disorder. Effective interventions can make substantial contributions to derogate the impact of acne severity on QOL.

Efficacy of Post-Operative Oral Prednisolone for the Control of Disease in Allergic Fungal Sinusitis

Background: Ambiguity persists regarding the dosage, frequency, and duration for the use of oral steroids in Allergic Fungal Sinusitis (AFS). Objective: To assess the efficacy of post-operative oral steroid (prednisolone) for the control of disease in Allergic Fungal Sinusitis. Methodology: This was a comparative study, conducted at Bahawal Victoria Hospital, Bahawalpur from January 2019 to March 2019. A total of 40 patients, aged 18 or above with weight over 50 kilograms, having proved Allergic Fungal Sinusitis (AFS) as per criteria defined by Deshazo and Swain, were recruited for this study. All the patients were enrolled within 14 days of excisive sinus surgery adopting endoscopic sinus surgery with or without open methods. Group A (n=20) received oral steroids while Group B (n=20) received a placebo. Patients of both groups also used fluticasone nasal spray and oral itraconazole. Evaluation of all the patients was done at the time of enrollment, 6 and 12 weeks. Data were analyzed by SPSS version 21. Results: Out of a total of 40 patients, 17 (42.5%) were males. After 6 weeks of continuous therapy in both the study groups, 14 (70%) patients of Group A showed complete relief of symptoms in comparison to none in Group B (p-value = 0.001). After 12 weeks of therapy having tapering off in both study groups, all patients in Group A had complete relief of symptoms in comparison to only one (5%) in Group B (p-value = 0.001). Conclusion: Oral steroids of prednisolone, along with inhaled steroids therapy for a minimum of 12 weeks after excisive sinus surgery were found efficacious for the control of disease in patients with Allergic Fungal Sinusitis.

Frequency of Suspected and Probable Case of Dengue in Adult Febrile Patients and their Knowledge about Dengue Fever

Background: Febrile illness is considered a frequent medical syndrome of dengue. Due to the increasing prevalence of dengue infectivity, appropriate diagnosis among patients helps regarding timely medical intervention, etiological examination as well as disease control. Objective: To estimate the frequency of suspected and probable cases of dengue in febrile patients and their knowledge about dengue fever, presenting at outdoor of Jinnah Hospital, Lahore. Methodology: It was a cross-sectional study, in which 400 adult febrile patients visiting at outdoor of Jinnah Hospital, Lahore were included. A convenient sampling technique was carried out. Among the total febrile patients included, the frequency of suspected and probable cases was calculated. Data was collected through a questionnaire, which was entered and analyzed using SPSS version 20.0. Results: Out of 400 patients, 36.5% were 21-30 years old and 53.5% were female. Among these patients, 100% had fever (>2 and <10 days), 31.8% had headache, 51.8% had myalgia and43.8% patients had arthralgia while 12.5% were suspected cases of dengue. Majority (97.2%) had knowledge that full sleeve shirt can prevent dengue, none of the respondents had knowledge regarding dengue symptoms and 76% of respondents had knowledge that dengue is fatal. For the majority (76%) of respondents, the main source of information regarding dengue was health teams. Conclusion: The study concluded that symptoms of dengue fever in the study patients, as well as the dengue, suspected cases were mainly headache, retro-orbital pain, myalgia, and arthralgia. The majority of the patients had knowledge about dengue prevention. Most of the adult febrile as well as suspected had no knowledge about the symptomology of dengue fever.

Atropine Induced Psychosis in Organophosphate Insecticide Poisoning and it's Management: A case series

Atropine is an established antidote in organophosphorus poisoning. It is an anticholinergic that inhibits the muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites including secretory glands, smooth muscle, and CNS sites. In the literature, the cases of atropine intoxication are not uncommon. We report a case series of five cases of atropine induced psychotic disorder in patients, who manifested with delirium, hallucinations, nervousness, drowsiness, weakness, irrelevant talk, flushing along with tachycardia, and non-reactive dilated pupils suggesting possible anti-cholinergic abuse. The patients reported at the Department of Medicine-Unit II, Sheikh Zayed Medical College/Hospital, Rahim Yar Khan, from January to June 2019. The patients were managed symptomatically by titrating down the atropine's dose, administration of benzodiazepine, and antipsychotics.

Mean difference of Electrolyte Level measured in Arterial Blood gases and measured in Laboratory in Children presenting in Pediatric Intensive Care Unit

Background: Electrolytes are measured in arterial and venous blood by arterial blood gas analyzer and the auto-analyzers respectively. Objective: To determine the mean difference in electrolyte level in arterial blood gases (ABGs) level versus laboratory serum electrolyte level in the children admitted in the pediatric intensive care unit. Methodology: This cross-sectional study was conducted at department of Pediatrics, the Children’s Hospital and Institute of Child Health, Lahore from 1st December 2015 to 31st May 2016. Total of 125 children fulfilling inclusion criteria were enrolled in the study from pediatric intensive care unit. The ABGs (whole blood) electrolytes were obtained immediately after collection, using ABGs analyzer. Serum electrolytes were analyzed in the central laboratory of the institution. Reports were assessed and levels of sodium and potassium was noted from reports of ABGs and laboratory. Results: Mean NA+ value on ABGs and from laboratory was 134.66 and 132.26 (p= 0.01). Mean K+ value from on ABGs and from laboratory was 4.51 and 4.28. (p= 0.071). In age group 1-5 and 6-10 years, K+ level was high in ABGs value (p-value=0.065 & p-value=0.073). However, in age group 11-15 years K+ level was significantly higher in ABGs value as that of laboratory value (p-value=0.014). The same trend was observed in male and female children that mean NA+ and K+ value with ABGs was significantly higher as compared to that of laboratory value. Conclusion: NA+ and K+ in arterial blood gases level were different from laboratory serum electrolyte level in children admitted to pediatric intensive care unit. Clinician should be aware of differences so that potential misdiagnosis does not occur and unnecessary treatment or investigation can’t be performed.

Hba1c: Point of Care Testing in Control of Type-2 Diabetes Mellitus in Population of Nowshera

Background: Diabetes mellitus is a highly prevalent non-communicable disease with a further implication of the development of life-threatening diseases like cardiovascular disease and stroke. Objectives: To determine the glycosylated hemoglobin levels utility in assessing the point of care testing in the control of diabetes mellitus in the population of Nowshera in a hospital-based study. Methods: This was a cross-sectional study, conducted in the department of Pathology in collaboration with the Department of General Medicine, Qazi Hussain Ahmed Medical Complex, Nowshera, from February 2019 to January 2020. Descriptive statistic was used for describing the variables. A Chi-square test was used for the association of Hba1c in gender groups. SPSS version 25 was used for data analysis. Results: Out of the total 119 patients, 44 (37%) were males and 75(63%) were females. The mean age with standard deviation was 53±9.5. The Mean Hba1c with standard deviation was 10.53± 2.38. Sixty-eight (57.1%) of the patients were in the age range 46-60 years. Eighty-eight (73.9%) were poorly controlled diabetics with Hba1c of >9%. Using the chi-square test it was observed that gender has no significant impact on the severity of the disease (p= 0.38). The relative risk of female gender and for age >50years was (RR=1.11). Conclusion: We observed that the majority of the patients had poorly controlled diabetes with Hba1c >9% which is an alarming situation. Age and gender play a very important role in the prognosis of diabetes mellitus.